PSYCHOTIC DISORDERS

Advanced Psychopathology
Anthony Sayegh, MD
University of Balamand
INTRODUCTION
• Many definitions over the decades
• Key element – Anosognosia (lack of insight)
• Anosognosia is a condition in which a person with a disability is
cognitively unaware of having it due to an underlying condition.
• The patient often does not ask for help – help is often sought out
by force.
• Singularity of clinical picture – one of the only admission by force
in Medicine.
INTRODUCTION
PSYCHOSIS
Delusion – fixed false belief
Hallucination – perception without an external stimulus
Disorganisation – speech and behavior (loose associations,
incoherence, tangentiality; erratic movements, inappropriate
emotional responses, neglect of personal hygiene)
Anosognosia
INTRODUCTION
Classification of psychosis
• Acute psychosis
• Chronic psychosis
• Schizophrenia
• Delusional disorder
• Other
• Schizophreniform disorder
• Schizotypal personality disorder
INTRODUCTION
Classification of psychosis Psychotic disorders

Dissociative Non-dissociative
psychotic disorders psychotic disorders

Schizophreniform
Brief Psychotic Delusional
Disorder and
Episode Disorder
Schizophrenia
INTRODUCTION
Brief Psychotic Episode
• Sudden onset
• Polymorphic delusions
• Mechanism
• Theme
• Lack of physical symptoms
• Quick resolution of episode
INTRODUCTION
Brief Psychotic Episode
Delusion – Mechanism
• Intuition
• Imagination
• Interpretation
• Illusion
• Hallucination
INTRODUCTION
Brief Psychotic Episode
Delusion – Theme
• Persecution
• Megalomania ; grandeur
• Jealousy
• Erotomania
• Reference
• Somatic
BRIEF PSYCHOTIC EPISODE
Diagnostic Criteria
A. Presence of one (or more) of the following symptoms:
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.

B. Duration of an episode of the disturbance is at least 1 day but

less than 1 month, with eventual full return to premorbid level of
functioning.
BRIEF PSYCHOTIC EPISODE
Diagnostic Criteria
C. The disturbance is not better explained by major depressive or
bipolar disorder with psychotic features or another psychotic disorder
such as schizophrenia or catatonia; and is not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a medication)
or another medical condition.

Associated Features
Individuals with brief psychotic disorder typically experience emotional
turmoil or overwhelming confusion. They may have rapid shifts from
one intense affect to another.
Although the disturbance is brief, the level of impairment may be
severe, and supervision may be required to ensure that nutritional and
hygienic needs are met and that the individual is protected from the
consequences of poor judgment, cognitive impairment, or acting on the
basis of delusions. There appears to be an increased risk of suicidal
behavior, particularly during the acute episode.
BRIEF PSYCHOTIC EPISODE
Early stages
• Disorder of the young adult (20 – 35 years)
• Sudden onset – “like thunder in an otherwise clear sky”
• Very clear change in baseline behavior
• Delusions can be accompanied by conduct disorders
• Pathological fugue – refers to a dissociative disorder characterized
by sudden, unplanned travel away from home or customary
work locations, along with an inability to recall one's past
(personal history) and confusion about the situation.
BRIEF PSYCHOTIC EPISODE
Full-blown clinical picture
What to expect?
• Delusions
• Hallucinations
• Depersonalization
• Alteration of time and space orientation without confusion
• Anxiety and worry
• Disorganized speech
• Disorganized behavior
BRIEF PSYCHOTIC EPISODE
Full-blown clinical picture
What to expect?
• Stunned or shocked affect
• Psychomotor retardation
• Psychomotor agitation
• Fugue pathologique
• Suicide attempt
BRIEF PSYCHOTIC EPISODE
Prevalence
Lifetime Prevalence – 1% to 3% of the general population.
2% to 7% of cases of first-onset psychosis in several countries.

Prognosis and Evolution

Psychiatric Emergency +++
• 1/3 remission
• 1/3 onset of schizophrenia
• 1/3 onset of bipolar disorder
BRIEF PSYCHOTIC EPISODE
Differential Diagnosis
• Other medical conditions (delirium, infection, metabolic
imbalance, brain tumor, Cushing syndrome)
• Schizophrenia and schizophreniform disorder
• Schizoaffective disorder
• Delusional disorder
• Substance-related disorders
• Depressive and bipolar disorders
BRIEF PSYCHOTIC EPISODE
Differential Diagnosis
Which is it?
• Isolated episode?
• Schizophrenia? Early inaugural phase in an otherwise healthy
individual
• Mood disorder? (Mania+++) Manic signs and delusional ideas

➙ Evolution
TIME WILL TELL!
BRIEF PSYCHOTIC EPISODE
Prognosis
Good prognosis
• Sudden start
• Precipitating factors
• Family history of BD
• Absence of PD
• Shorter duration of episode
• Good response to treatment
• Positive insight
BRIEF PSYCHOTIC EPISODE
Prognosis
Bad prognosis
• Progressive onset
• Schizoypical personality disorder
• Absence of BD family history
• Family history of schizophrenia
• Longer duration
• Bad response to treatment
• Poorer insight
BRIEF PSYCHOTIC EPISODE
Treatment
HOSPITALISATION IS URGENT
• Fast treatment = better outcome
• Initiate and adapt treatment
• Keep the patient safe from harm
• Detect and minimise side effects
• Objectively qualify evolution
SCHIZOPHRENIFORM DISORDER
Overview
The characteristic symptoms of schizophreniform disorder are
identical to those of schizophrenia.
It is distinguished by its difference in duration: the total duration of
the illness, including prodromal, active, and residual phases, is at
least 1 month but less than 6 months.
The duration requirement is intermediate between that for brief
psychotic disorder, which lasts more than 1 day and remits by 1
month, and schizophrenia, which lasts for at least 6 months.
The diagnosis of schizophreniform is made when an individual is
symptomatic for less than the 6 months’ duration required for
the diagnosis of schizophrenia but has not yet recovered.
SCHIZOPHRENIA
Overview
The characteristic symptoms of schizophrenia involve a range of
cognitive, behavioral, and emotional dysfunctions, but no single
symptom is pathognomonic of the disorder.
The diagnosis involves the recognition of a constellation of signs
and symptoms associated with impaired occupational or social
functioning.
Individuals with the disorder will vary substantially on most
features, as schizophrenia is a heterogeneous clinical syndrome.
SCHIZOPHRENIA
Overview
Psychotic manifestations
• Delusions
• Hallucinations FOR AT LEAST 6 MONTHS

• Disorganized speech WITH SOCIAL IMPACT &

DYSFUNCTION
• Disorganized behavior
• Negative symptoms
SCHIZOPHRENIA
Epidemiology
The estimated lifetime prevalence of schizophrenia is
approximately 0.3% – 1%, with variation across nations.

Studies have shown increased prevalence and incidence of

schizophrenia for some groups based on migration and refugee
status, urbanicity, and the economic status.

The sex ratio is M:F = 1:1.

SCHIZOPHRENIA
Evolution
Eliminated subtypes from DSM-IV – paranoïd, disorganised,
catatonic, undifferentiated, residual

Pathophysiology
Hypothesis – alteration in dopaminergic neurons
Based on:
• Reduction in delusions when dopamine receptor antagonists are
administered – neuroleptic drugs (antipsychotics)
• Emergence of delusions when dopamine receptor agonist are
administered – L-dopa, amphetamines
SCHIZOPHRENIA
Diagnostic criteria
A. Two of the following, each present for a significant portion of time
during a 1-month period. At least one of these must be (1), (2), or
(3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or
avolition).
SCHIZOPHRENIA
Diagnostic criteria
B. Level of functioning major areas (work, interpersonal relations, or self-care)
is markedly below the level achieved prior to the onset.

C. Continuous signs of the disturbance persist for at least 6 months. This 6-

month period may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance may
be manifested by only negative symptoms or by two or more symptoms
present in an attenuated form (e.g., odd beliefs, unusual perceptual
experiences).

D. Schizoaffective disorder and depressive or bipolar disorder with psychotic

features have been ruled out because either 1) no major depressive or manic
episodes have occurred concurrently with the active-phase symptoms, or 2) if
mood episodes have occurred during active-phase symptoms, they have been
present for a minority of the total duration of the active and residual periods of
the illness.
SCHIZOPHRENIA
Diagnostic criteria
E. The disturbance is not attributable to the physiological effects
of a substance (e.g., a drug of abuse, a medication) or another
medical condition.
F. If there is a history of autism spectrum disorder or a
communication disorder of childhood onset, the additional
diagnosis of schizophrenia is made only if prominent delusions or
hallucinations, in addition to the other required symptoms of
schizophrenia, are also present for at least 1 month (or less if
successfully treated).
SCHIZOPHRENIA
Clinical features
Contact with the patient can vary from one moment to another and
is not very specific. It causes an impression of oddness, of
distance.
The patient most often remains distant and enigmatic; his/her
vocabulary can be marked by neologisms and an often trivial
style.
In paranoid delusions, the delusional process is rich and multiple.
All mechanisms and themes can be found.
More specifically, ideas of persecution (+++), grandeur, and
reference.
SCHIZOPHRENIA
Clinical features
Auditory (+++) and cenesthetic (+++) hallucinations are very
frequent.
Olfactory (+) and visual (+) hallucinations are much rarer.
Classically, the subject also lives numerous experiences where
the world seems to concern him (delusion of reference).
These delusions take the form of an idea with uncontrollable and
pathological character.
Another essential element is the presence of mental automatism
syndrome which describes a scarcity of “the private property of
thought”.
SCHIZOPHRENIA
Clinical features
Dissociation, often found in schizophrenia, is the loss of unity of
the personality of the subject, which is evaluated at the level of
thought, affectivity and in behavior.
It is, thus, responsible for the ambivalence, oddness and
detachment from reality often found in these patients.
Thought process is altered and no longer linear.
Indirect signs – blurred, discontinuous thinking, diffluency of
speech, blockages (barrage and mental fading), stagnation of
thought, perseverance.
SCHIZOPHRENIA
Clinical features
Speech is also altered. There is a distortion of the verbal system
with conversational disorders (mutism, verbal impulses, etc.),
syntactic and semantic disorders (neologisms, keywords, etc.)
There is an alteration of the logical system with absurd, unreal
thinking and morbid rationalism. (Morbid rationalism refers to a
cold, overly analytical approach to life that disregards emotional
and ethical considerations.)
SCHIZOPHRENIA
Risk Factors and Vulnerability
• Genetic risk factor
• 40% increased risk in homozygotic twins
• Environmental risk factor
• Early urban setting
• Social isolation
• Immigration
• Traumatic experience in childhood
• Physical trauma in mother during pregnancy
• Prenatal infections in mother
• Childbirth complications
• Recreational drugs
SCHIZOPHRENIA
Prognosis
Better prognosis if:
• Late onset (after 18 years)
• Precipitating life stressor
• Complete remission at one point during treatment
• Female gender
• Elevated socio-economic status
• Acute sudden start
• Early therapeutic intervention
SCHIZOPHRENIA
Complications
Depressive syndrome
Suicide
Self-harm
Verbal and physical aggression
Social isolation
Family separation
SCHIZOPHRENIA
Treatment Strategies
• Early detection
• Symptom management
• No treatment for the cause of schizophrenia
• Hospitalisation (aggressivity, self-harm)
• Rule out differential diagnoses
• Psychometric testing
• Prevent complications
• Prevent comorbidities
DELUSIONAL DISORDER
Overview
Delusional disorders are characterized by the presence of a
chronic delusional syndrome that is not marked by oddness.
In classic terminology, we speak of chronic non-dissociative
psychosis.
These delusional disorders are characterized by delusional ideas
involving situations that can be encountered in reality such as:
being loved or deceived, being pursued, poisoned, suffering
from an illness, etc.
Furthermore, patients do not present with dissociation, marked
alterations in functioning, singularities or significant behavioral
oddities.
DELUSIONAL DISORDER
Epidemiology
Delusional disorder is under-evaluated because patients rarely
seek medical advice.
The estimated lifetime prevalence is around 0.02% - 0.03%.
The average age of onset is 40 years old.
There is only one theme and one mechanism.
DELUSIONAL DISORDER
Diagnostic Criteria
A. The presence of one (or more) delusions with a duration of 1
month or longer.
B. Criterion A for schizophrenia has never been met.
Note: Hallucinations, if present, are not prominent and are related
to the delusional theme (e.g., the sensation of being infested with
insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications,
functioning is not markedly impaired, and behavior is not obviously
bizarre or odd.
DELUSIONAL DISORDER
Diagnostic Criteria
D. If manic or major depressive episodes have occurred, these have
been brief relative to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of
a substance or another medical condition and is not better
explained by another mental disorder, such as body dysmorphic
disorder or obsessive-compulsive disorder.
Specify subtype
DELUSIONAL DISORDER
Clinical features
According to the DSM-5, the most common themes, from most to least
prevalent, include:
1. Persecutory Delusions – Beliefs that one is being targeted or
harassed (most common).
2. Grandiose Delusions – Inflated sense of self-importance, power, or
identity.
3. Somatic Delusions – Beliefs about having a serious medical condition
or physical defect.
4. Religious Delusions – Beliefs related to religious themes, often
involving a sense of being chosen or having a special mission.
5. Erotomaniac and Jealousy Delusions – Beliefs that another person,
often of higher status, is in love with the individual.
DELUSIONAL DISORDER
Clinical features
Erotomaniac and Jealousy Delusions
Highly interpretative in mechanism.
They correspond to passionate delusions, in which the individual
manifests:
- The delusional belief of being loved by someone usually of higher
social status (involving the three phases of hope, disappointment,
and resentment).
- Or the delusional belief that their partner is unfaithful.

In both cases, the delusion is organized in sector, meaning it only

affects certain emotional aspects related to the theme of the
delusion.
DELUSIONAL DISORDER
Clinical features
Persecutory Delusions
Former "paranoid delusion of interpretation”, no longer in the DSM.
It focuses on themes of persecution and more or less organized
conspiracies against the individual.
The concealed delusion gradually intensifies day by day, with each life
incident immediately interpreted as additional evidence.
Sometimes, the delusion centers around a perceived injustice that
must be rectified through the law.
The individual then engages in repeated actions seeking compensation
from the justice system.
There may be a risk of acting out against the individual considered
responsible for the persecution, with real danger in this case.
CATATONIA
Overview
Catatonia can occur in the context of several disorders, including
neurodevelopmental, psychotic, bipolar, and depressive
disorders, and other medical conditions.
Catatonia is defined by the presence of 3 or more of 12
psychomotor features.
The essential feature of catatonia is a marked psychomotor
disturbance that may involve decreased motor activity,
decreased engagement during interview, or excessive and
peculiar motor activity.
The clinical presentation of catatonia can be puzzling, as the
psychomotor disturbance may range from marked
unresponsiveness to marked agitation.
CATATONIA
Overview
During severe stages of catatonia, the individual may need careful
supervision to avoid self-harm or harming others. There are
potential risks from malnutrition, exhaustion, thromboembolism,
pressure ulcers, muscle contractions, hyperpyrexia and self-
inflicted injury.

It constitutes a medical and psychiatric emergency.

CATATONIA – ASSOCIATED WITH ANOTHER
MEDICAL OR PSYCHIATRIC CONDITION
Diagnostic Criteria
The clinical picture is dominated by three (or more) of the following symptoms:
1. Stupor (i.e., no psychomotor activity; not actively relating to environment).
2. Catalepsy (i.e., passive induction of a posture held against gravity).
3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
5. Negativism (i.e., opposition or no response to instructions or external stimuli).
6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
7. Mannerism (i.e., odd, circumstantial caricature of normal actions).
8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
9. Agitation, not influenced by external stimuli.
10. Grimacing.
11. Echolalia (i.e., mimicking another’s speech).
12. Echopraxia (i.e., mimicking another’s movements).
CATATONIA – ASSOCIATED WITH ANOTHER
MEDICAL OR PSYCHIATRIC CONDITION
Treatment
• Benzodiazepines
• Supportive treatment (hydration, nutrition)
• ECT

TREAT UNDERLYING
PATHOLOGY
PSYCHOTIC DISORDERS
TREATMENT
Antipsychotic Drugs
These are classified into first-generation (conventional)
antipsychotics (FGA) or second-generation antipsychotics
(SDAs, novel or atypical) antipsychotics.
Historically, conventional antipsychotics were successful in
treating the positive symptoms of schizophrenia with worsening of
negative, cognitive, and mood symptoms.
Atypical antipsychotics have been suggested to show
improvement in (1) positive symptoms such as hallucinations,
delusions, disordered thoughts, and agitation and (2) negative
symptoms such as withdrawal, flat affect, anhedonia, poverty of
speech, catatonia, and cognitive impairment.
PSYCHOTIC DISORDERS
TREATMENT
Antipsychotic Drugs
FGA
• Chlorpromazine (Largactil)
• Haloperidol (Haldol)
• Zuclopenthixol (Clopixol)

• Promethazine (Prometal)
PSYCHOTIC DISORDERS
TREATMENT
Antipsychotic Drugs
SGA
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Aripiprazole (Abilify)
• Clozapine (Leponex)
PSYCHOTIC DISORDERS
TREATMENT
Antipsychotic Drugs
Administration
Oral (maintenance therapy)
Intramuscular (used if urgent and fast action is needed)
Long-acting injectables (best for non-compliant patients)